SGEM#289: I Want a Dog to Relieve My Stress in the Emergency Department

Date: April 9th, 2020 Reference: Kline et al. Randomized trial of therapy dogs versus deliberative coloring (art therapy) to reduce stress in emergency medicine providers. AEM April 2020 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com Case: It has been a hard shift. You wish you could say “uncharacteristically”, but recently all your shifts in the emergency department have felt a little hard. The increased workload due to COVID-19 hasn’t been helping. You sit down to chart after a difficult resuscitation, and the charge nurse, seeing that you look a little stressed, asks if you would like to take a break to play with a dog. Background: Medicine is an incredibly rewarding profession. However, it is undeniably marked by significant levels of stress. Reports of burnout are high across medicine, and even higher in emergency medicine (1,2). A study of USA physicians showed that they had more than  50% with at least one symptom of burnout. Emergency physicians reported the highest prevalence of burnout at around 70% (3). Burnout is associated with a loss of empathy and compassion towards patients, decreased job satisfaction, and shorter careers in medicine (4,5). It has also been associated with negative impacts on patient care including self-perceived medical error (6), risk of medical errors (7), and quality of care (8,9). We have covered burnout a few times on the SGEM including my own personal experience of being on the edge of burnout: Five Tips: To Avoid Emergency Medicine Burnout SGEM#178:Mindfulness – It’s not Better to Burnout than it is to Rust SGEM Xtra: On the Edge of Burnout ACEM18 SGEM Xtra: CAEP Wellness Week 2019 YouTube: Being on the Edge of Burnout One Year Later There is some prior literature that exposure to animals decreases stress (10,11). Theoretically, time spent deliberately coloring as a mindfulness practice could also decrease stress (12). Therefore, these authors designed a prospective, randomized trial comparing the effects of dog therapy, deliberate coloring, and control on stress levels for emergency department providers (13). Clinical Question: Does dog therapy result in lower perceived stress than deliberate coloring or control when applied as a break during an emergency medicine shift? Reference: Kline et al. Randomized trial of therapy dogs versus deliberative coloring (art therapy) to reduce stress in emergency medicine providers. AEM April 2020 Population: Emergency care providers, including nurses, residents, and physicians, from a single center emergency department. Exclusions: Dislike, allergy, fear, or other reason not to interact with a therapy dog. Intervention: There were two interventions, which occurred approximately midway through the provider’s shift. Dog therapy consisted of an interaction with a therapy dog, which providers could pet or touch if they wished. The coloring group was provided with three mandalas to choose to color and a complete set of coloring pencils. Both of these activities occurred in a quiet room, physically separated from the clinical care area, with no electronic devices, telephone, window, or overhead speaker. Comparison: A convenience sample of providers that were not offered any break. Outcomes: Primary Outcomes: There were two primary outcomes. The first was a self-assessment of stress using a visual analogue scale. The second was a 10-item validated perceived stress scores, altered to focus providers on the past several hours rather than months, as it was originally designed. These were both measured at the beginning of the shift, about 30 minutes after the intervention, and near the end of the shift. Secondary Outcomes: They looked also looked at a FACES scales as a measure of stress, and provider cortisol levels. Dr. Jeff Kline This is an SGEMHOP episode which means we have the lead author on the show.  Dr. Jeff Kline (@klinelab) is the Vice Chair of Research in Emergency Medicine and a professor of physiology, Indiana University School of Medicine. He is the editor in chief of AEM, creator of Pulmonary Embolism Rule-out Criteria (PERC) Rule and has published extensively in the area of pulmonary emboli. Authors’ Conclusions: "This randomized, controlled clinical trial demonstrates preliminary evidence that a five minute therapy dog interaction while on shift can reduce provider stress in Emergency Department physicians and nurses.”  Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. No The randomization process was concealed. Unsure The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). No The patients in both groups were similar with respect to prognostic factors. Unsure All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Unsure Key Results: They enrolled 127 providers, but five withdrew because they thought their shift was too busy to participate. 47% were resident physicians, 23% were attending physicians, and 30% were nurses. They were most frequently (60%) enrolled during an evening shift. The coloring intervention took a median of five minutes and 26 seconds. In the dog group, providers spent a median of five minutes and 49 seconds with the dogs and had significant interaction with both the dog and the dog’s handler. Primary Outcome: Stress based on the VAS was the same in all three groups at the beginning of the shift (18mm) but rose in the coloring group and fell in the dog group. Stress based on the validated stress score rose in the control group, but otherwise was not statistically significant. Secondary Outcomes: In all three groups, cortisol levels were highest at the beginning of the shift and decrease over time. The cortisol level fell more in both intervention groups. We asked Jeff ten questions to get a greater understand of his publication. Listen to the SGEMHOP podcast to hear all of his answers. 1) Allocation Concealment: Allocation concealment is one of those EBM terms that gets thrown around a lot but isn’t often discussed. It’s really important, because if you can guess what group you are going to be in, it might affect your decision to join the study. For example, in this study, if I thought I was going to be in the dog group, I would definitely say yes, but I have no interest in coloring, so probably would have said no. Can you comment on your allocation concealment procedures and whether you think they are adequate? 2) Nocebo / Convenience Sample: First, the idea of nocebo is fascinating, and it would be great if you could explain your logic for not randomizing the control group to the listeners. Second, I worry about the convenience sample as a source of bias. The study’s objective was not blinded, so it is possible that the convenience sample could have been selected on particularly stressful days or particularly not stressful days, which would impact the results.  3) Two Primary Outcomes: This paper had two co-primary outcomes, but as we frequently say on the SGEM, “there can only be one.” Perhaps as the editor in chief of Academic Emergency Medicine, you can settle this one for us.  Are you really allowed to have more than one primary outcome? 4) Statistical vs Clinical Significance: Overall, the results suggest a statistical decrease in stress in the group exposed to dogs. However, it is unclear whether the magnitude of change was large enough to be noticeable. Do you think the results are clinically significant? 5) Blinding: Obviously, it is essentially impossible to blind a study like this, but the lack of blinding does make it harder to interpret the subjective feelings of stress. It is possible that people just like dogs (who doesn't), and the lower scores don’t really reflect stress. 6) Short vs Long Term Outcomes: You focused on same-day stress, but presumably for burnout, long term outcomes might be more important. Do you think these results will extrapolate to longer term benefits? 7) Language: I noticed that one of the coloring options had crude language. I found the message funny, and it would have lifted my spirits on shift, but I can imagine problems if the completed picture accidentally found its way into a patient’s hands. They might not understand the emergency provider’s darker humour. 8) Harms from Dogs: Did you consider potential harms from the interventions? For example, you let participants opt out if they had dislike, fear, or had allergies to dogs. Personally, I love dogs, but I am also incredibly allergic. I can imagine ignoring my allergies to play with the dog mid shift, but then regretting that choice and having increased stress as I trying to manage my remaining patients with incredibly itchy eyes and an endlessly runny nose. Puppies PRN and Dogs on Demand 9) Scheduling the Intervention vs Stress Relief on Demand: In this study, the intervention was scheduled for a specific time during the shift. Emergency shifts aren’t very amenable to strict schedules. In fact, when someone tries to schedule something at a specific time during one of my shifts, it tends to increase stress. I wonder whether interventions like this would be more effective if they were available when the provider felt they needed them – such as after a stressful resuscitation.